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Tuesday, May 27, 2014

Clinical communication 101 or how many ways can you ask what do you feed your dog?

Would you tell your vet that you feed your dog treats?

The
first day of the conference was intense. After a 6.45am start for a breakfast
lecture by Charles Kuntz on shoulder instability as a cause of forelimb
lameness in dogs, delegates were set loose to choose from one of eight streams.
I tried to focus on ethics and client communication yesterday as areas of
interest, though I did get waylaid at the Specialised Animal Nutrition stand
checking out the new flavours of hay for the guinea pigs (for the cavy lovers
out there, Western Timothy & Carrots looks good).

It’s
like one big veterinary school camp. Everywhere you go there are former
colleagues, people from uni, Faculty, luminaries in the field, students…it’s
overstimulation-central. So quite a task to blog daily. But here we go.

AssociateProfessor Jason Coe who holds the Nestle Purina Canada Chair in Communication
gave a number of talks on overcoming barriers to communication in the consult
room. Communication in the veterinary setting is challenging but it’s a subject
that doesn’t always get the attention it deserves.

Good
communication is associated with good clinical outcomes, both in human medicine
and vet land. But there are plenty of barriers to communication – time
pressures, hidden expectations (on behalf of client or vet), misinformation
from other sources and so on.

Getting
a good history is so important. But in one study, only 61 per cent of vets
asked about diet in a consultation (it may have been because the animal
presented for something not nutrition related, e.g. a cat fight abscess, but it
may have been for a vaccination).

When
asked what they fed their pet, 61 per cent of clients only gave one item; 28%
identified two foods and only 8 per cent of people mentioned treats. Mostly (75
per cent of the time) vets didn’t probe further. A lot of clients perceived a
hidden agenda in the question “what are you feeding your pet” so they shut
down. Perhaps they were worried they weren’t feeding the “right” brand, or felt
they might be judged.

We practiced taking nutrition histories from each other
and I will admit I wasn’t up front about some of Phil’s treats as I thought the
question was really about what do I feel him as a main (and no, he doesn’t get
an entrée and dessert)(doesn't stop him asking though).

Using
a different type of question can lead to better answer. Dr Coe suggested
something like “can you tell me everything that Phil eats throughout the day,
starting from first thing in the morning right through to the end of the day.”

Vets
tend to have a fear of asking open-ended questions lest it result in a lengthy
answer. In a previous study by Shaw, Adams, Bonnett et al, 50 veterinarians
consulted 300 clients. On average they used two open-ended questions and 13
closed questions. Around one quarter of interactions didn’t incorporate a
single open-ended question! (An Aussie study by McArthur and Fitzgerald of 24
vets talking to 63 clients found that 15% didn’t contain open ended questions).

But
open-ended questions yield good info and they don’t cost too much time. People
on average took 13 seconds to respond to an open-ended question versus 5
seconds to respond to a closed question.

Time
pressures were seen as one of the biggest barriers to communication, yet taking
the time at the beginning of the consult to find out what the client’s concerns
are SAVED time.

In
one study of 334 vet/client actions, 37% of the time the vet asked for client’s
concerns at the outset, took a bit of time to develop a rapport and took a good
history.

But
taking time saves time. People who just verballed their clients and didn’t
listen to their concerns took around 12 minutes in consultation, whereas those
who spent time asking about concerns took around 10.5 minutes.

Veterinary Ethics: Navigating Tough Cases

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